A 14-year-old girl is brought to the office due to heavy vaginal bleeding. Since menarche at age 13, menses have been irregular but not painful. Her last menstrual period was 6 weeks ago, and her current menses started 7 days ago. She is soaking through a thick pad every 2 or 3 hours and bled through her clothing overnight. She has no history of recurrent epistaxis or bruising. The patient has no chronic medical conditions or previous surgeries. Her mother required a blood transfusion with delivery, but has had no other bleeding episodes. Blood pressure is 110/60 mm Hg and pulse is 65/min. The external genitalia are normal and consistent with sexual maturity rating (Tanner stage) 4 development. The abdomen is nontender, nondistended, and has no masses. On pelvic examination, there is dark red bleeding from the cervical os. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?

Question

A 14-year-old girl is brought to the office due to heavy vaginal bleeding.  Since menarche at age 13, menses have been irregular but not painful.  Her last menstrual period was 6 weeks ago, and her current menses started 7 days ago.  She is soaking through a thick pad every 2 or 3 hours and bled through her clothing overnight.  She has no history of recurrent epistaxis or bruising.  The patient has no chronic medical conditions or previous surgeries.  Her mother required a blood transfusion with delivery, but has had no other bleeding episodes.  Blood pressure is 110/60 mm Hg and pulse is 65/min.  The external genitalia are normal and consistent with sexual maturity rating (Tanner stage) 4 development.  The abdomen is nontender, nondistended, and has no masses.  On pelvic examination, there is dark red bleeding from the cervical os.  Urine pregnancy test is negative.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d99b_40fb_bc81_a3424bb8a161_MD0003_00 This patient has abnormal uterine bleeding (AUB), defined during adolescence as menstrual bleeding <21 days or >45 days apart. In adolescents who have recently undergone menarche, immaturity of the hypothalamic-pituitary-ovarian axis fails to produce appropriate quantities and ratios of gonadotropin-releasing hormone, and therefore LH and FSH, to induce ovulation. As a result, during the first few years post menarche, the majority of menstrual cycles are anovulatory and present as painless, irregular, heavy bleeding. During the menstrual cycle, the endometrium proliferates in response to estrogen stimulation. Normally, progesterone is produced in increased amounts by the corpus luteum following ovulation, and withdrawal of this progesterone as the corpus luteum degenerates results in menses. However, in anovulatory cycles, progesterone is not produced due to the lack of corpus luteum formation (which occurs after release of the oocyte). The endometrium continues to proliferate due to unopposed estrogen and eventually sheds, leading to breakthrough bleeding. Treatment of the AUB is with either progestin only (to stabilize the endometrium) or with combined oral contraceptives to help regulate menses. anovulatory cycles (Choice A) Cervical inflammation occurs with acute cervicitis and typically presents with intermenstrual or postcoital spotting rather than irregular heavy menses. (Choice B) Adenomyosis, characterized by endometrial implantation within the myometrium, typically presents in parous women age >40 with heavy, painful, regular menses and chronic pelvic pain. (Choice D) Von Willebrand disease (eg, impaired platelet adhesion) can present with heavy menstrual bleeding; however, there is also typically a history of recurrent epistaxis, easy bruising, and gingival bleeding, which are not seen in this patient. (Choice E) Monoclonal myometrial proliferation is the mechanism of leiomyoma (eg, uterine fibroid) formation. Patients with leiomyoma typically present with heavy and prolonged but regular menses. Educational objective: In adolescents who have recently undergone menarche, the immature hypothalamic-pituitary-ovarian axis results in anovulation and causes abnormal uterine bleeding. References: Dysfunctional uterine bleeding in adolescent girls and evaluation of their response to treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24192679)

A 14-Year-Old Girl Is Brought to the Office Due to Heavy